Challenges of Antiretroviral Therapy in the Developing WorldPresenter: Joep M.A. Lange, M.D., Ph.D., University of Amsterdam, The Netherlands

Dr. Lange gave the most interesting talk of the afternoon. It was reassuring to see him newly humbled. He began by recognizing the tremendous difficulties of implementing antiretroviral therapy in the developing world, and how his opinion has changed in the last year. He then reviewed what, in his opinion, are the challenges we are facing.

The first challenge is the lack of necessary political commitment from the countries involved. There are many problems -- social, economic, even martial -- affecting these countries. HIV may seem to us an important problem, but to many of the politicians in these countries, HIV and AIDS does not reach the magnitude of some of the other problems they are facing.

The second challenge is the cost of the drugs. Although drug prices have decreased dramatically, and some countries are even now using generic drugs and breaking patents, the cost per day of therapy (maybe $2 or $3 a day) is still overwhelming for some or most developing countries. The cost of monitoring therapy has also become an important limiting factor in antiretroviral therapy in those settings.

The third challenge is the limitation on infrastructure in the developing world: the lack of labs, the lack of distribution systems that can deliver medications even to remote areas, the lack of refrigeration, etc.

The fourth -- and probably most formidable -- challenge for implementation of antiretroviral therapy is the lack of human expertise in dealing with HIV and its treatment.

The fifth challenge is the lack of a common agenda among investigators and politicians in the developed world, the lack of leadership and the lack of programs to implement therapy at a global level.

Dr. Lange proposed potential solutions to these challenges. Regarding the political commitment, he basically said that now is the time to start providing antiretroviral therapy. We should not worry about the "immensity" of the task at hand. We should forget any second thoughts regarding the lack of "equity" (i.e., some patients will not be reached) in our interventions. He also pointed out the importance of involving the private sector in this mission: if the cost of antiretroviral therapy goes down (as is happening) the economic benefits of therapy will easily be seen by private companies working in these regions of the world. Other things can also be done to try to reduce the costs of the medications: Dr. Lange suggested that developing countries should establish global bulk purchasing groups, and that monitoring of therapy should be cheaper or not done at all. He also argued against the idea of making all antiretrovirals available everywhere. He suggested that only one or two consecutive regimens (the simplest) should be implemented in the developing world. The programs that deliver therapy should be linked to already existing programs like tuberculosis prevention programs and should be adapted to the local reality. Developing expertise is the most daunting challenge. Taking care of HIV-infected individuals has to be a reasonable career path for physicians and other health care providers in these countries if we want to succeed.

He concluded his sobering, but at the same time very clear talk, with a slide stating, "It is time to stop playing around."

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